ARTICLE IN BRIEF
Over the past 15 years, experts point to a move away from treating backpain with painkillers and surgery, instead focusing onself-management, mindfulness, and cognitive-behavior therapy.
There has been little progress in establishing effective evidence-based treatments for back pain since Neurology Today first published an editorial in 2001, advising against the use of spinal epidural steroid injections. [See “Why Neurologists Should Not Administer the Prescriptive Steroid Shot in the Back,” http://bit.ly/NT-steroid-back.] In fact, various analyses of research on back pain have found that many of the widely-used options provide limited benefits at best.
Indeed, managing back pain is made more challenging by the fact that many different types of back pain exist — stenosis and radiculopathy, for example — which may manifest differently.
Earlier this year the Agency for Health Research Quality published a comprehensive review of research on back pain treatments, and concluded that medications provide only small, short-term help and that there is little evidence to support fusion surgery or spinal injection of steroids.
While most professional guidelines are in alignment with the report's findings, these treatments continue to be used as first-line options.
“A lot of what we had been using simply does not work,” said Gary M. Franklin, MD, MPH, FAAN, research professor in neurology and environmental health at the University of Washington in Seattle. “What has happened with opioid medications is horrible, and what is going on with fusion surgery is just as bad.”
In the Washington state workers' compensation system, for example, long-term problems with fusion surgery are just one case in point, said Dr. Franklin, who also serves as medical director or the Washington State Department of Labor and Industries.
“After 10 years or more, 44 percent of fusion patients are terribly disabled and are moving onto the Social Security rolls,” he told Neurology Today. “I believe the highest priorities today in back pain are to halt or significantly curtail the use of opioids, stop invasive procedures, and develop protocols for cognitive behavioral therapy and graded exercise.”
An emerging body of evidence points to coordinated, multidisciplinary rehabilitation focused on teaching patients how to better cope with their pain through cognitive-behavioral therapy, meditation, and other mindfulness techniques, Dr. Franklin said. Programs that combine active physical therapy with cognitive-behavioral therapy have the potential to change how back pain is treated, he said.
WASHINGTON STATE PROGRAM
An ongoing initiative in Washington State is improving quality and outcomes by providing financial incentives to providers to adopt best practices, coupled with organizational support and care management activities.
“The key here is to improve self-efficacy — to help patients to help themselves,” Dr. Franklin said. “We used to give them tools like drugs or surgery, but now we are trying to teach them to develop their own tools through cognitive therapy, exercise, meditation and mindfulness.”
Washington State has developed a population-based care delivery system to manage pain and underlying issues that may be contributing to long-term problems that prevent back pain patients from returning to work. It includes individual patient care coordinators who monitor and facilitate collaboration across a range of interventions; about one-half of providers are currently participating. The state is now in the planning stages of expanding the program.
“This is how the Veterans Administration has been approaching post-traumatic stress disorder for some time, and we believe the same kind of coordinated care can help with back pain,” said Dr. Franklin.
Janna L. Friedly, MD, associate professor at the University of Washington, and medical director of outpatient rehabilitation medicine at Harborview Medical Center, told Neurology Today that interest in cognitive-behavioral therapy and mindfulness training for back pain patients is a relatively new trend.
“What we are finding is that there are ways to change the psychology of chronic pain patients using these techniques to get them to participate in behavioral and exercise programs that can help them deal with back pain.”
The biggest barrier to wider adoption of such coordinated patient care, however, is that the health care system in the United States remains largely driven by the current fee-for-service platform that is biased toward surgery and rewards many techniques that lack supporting evidence, she said. Compounding the problem is the fact that most patients are unaware that these techniques are unlikely to help them overall.
The situation is “unlikely to change until these things [the barriers to coordinated patient care and a lack of awareness about helpful techniques] change,” she said.
Although there is mounting evidence that techniques like cognitive-behavioral therapy and meditation can help back pain patients, not everyone is convinced, she continued.
“These are still controversial and there is a lot of pushback. Some states and communities are more progressive and are adopting this approach, but it is going to take greater awareness of the data before acceptance becomes more widespread.”
The epidemic of opioid overdoses and deaths, and efforts to curtail over-prescription and diversion, are playing a key role in changing the treatment milieu toward alternative behavioral approach to pain management, said Richard A. Deyo, MD, the Kaiser Permanente professor of evidence-based family medicine at the Oregon Health and Science University in Portland.
“Finding alternatives has never been more important,” he told Neurology Today. “This trend toward cognitive behavioral therapy and mindfulness is being largely driven by the fact that long-term opioid treatment is not only ineffective but extremely dangerous.”
He pointed to mindfulness research by Jon Kabat-Zinn, PhD, director of the Center for Mindfulness in Medicine, Health Care, and Society at the University of Massachusetts Medical School, and others, who are demonstrating through randomized clinical trials that such techniques can be effective.
In March, two studies published in the Journal of the American Medical Association concluded that mindfulness and cognitive-behavioral therapy can have a significant impact in helping individuals cope with low back pain. One paper, by investigators at the University of Pittsburgh School of Medicine, showed that a “mind-body program” for chronic low back pain improved both short-term function and long-term pain.
In the other, University of Washington researchers reported that both mindfulness-based stress reduction and cognitive-behavioral therapy resulted in greater improvement in chronic low back pain and functional limitations at 26 weeks when compared with other treatment.
“People are looking for other approaches, and with what we have learned and are learning about neuroplasticity, these techniques are of major importance,” said Dr. Deyo. “There is growing acceptance of mindfulness in stress and pain reduction, and the field has expanded in the last few years.”
Educating patients with back pain and their doctors about these approaches remains a major barrier, but it would likely be reduced if more coordinated multidisciplinary programs were in place, he noted.
“This is a real challenge. Patients and doctors are looking for silver bullets, and what we know is that there aren't any. Chronic back pain is like hypertension or diabetes — we can't cure patients, but we can teach them self-management,” he said.
According to Dr. Deyo, there should be more shared decision-making, and patients should be made more aware of the limitations of many of the options they are currently being offered.
“We are seeing a shift in this direction, but there is still a long way to go. Part of the problem is, as professionals, we have not had a united front on this issue. Many providers are still advertising that they have the ‘cure’ when, in fact, patients need to be given accurate information about what to expect from these treatments. They need realistic outcomes based on the evidence, and to understand their own role in symptom self-management.”
EXPERTS: WHERE TREATMENT FOR BACK PAIN IS HEADED